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Chiu YC, Katsura M, Takahashi K, Matsushima K, Demetriades D. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the presence of associated severe traumatic brain injury: A propensity-score matched study. Am J Surg 2024; 237:115798. [PMID: 38944625 DOI: 10.1016/j.amjsurg.2024.115798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/04/2024] [Accepted: 06/12/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Experimental work suggested that resuscitative Endovascular Balloon Occlusion of the aorta (REBOA) preserves cerebral circulation in animal models of traumatic brain injury. No clinical work has evaluated the role of REBOA in the presence of associated severe traumatic brain injury (TBI). We investigated the impacts of REBOA on neurological and survival outcomes. METHODS Propensity-score matched study, using the American College of Surgeons Trauma Quality Improvement Program database. Patients with severe TBI patients (Abbreviated Injury Scale ≥3) receiving REBOA within 4 h from arrival were matched with similar patients not receiving REBOA. Neurological matching included head AIS, pupils, and midline shift. Clinical outcomes were compared between the two groups. RESULTS 434 REBOA patients were matched with 859 patients without REBOA. Patients in the REBOA group had higher rates of in-hospital mortality (63.6 % vs 44.2 %, p < 0.001), severe sepsis (4.4 % vs 2.2 %, p = 0.029), acute kidney injury (10.1 % vs 6.6 %, p = 0.029), and withdrawal of life support (25.4 % vs 19.6 %, p = 0.020) despite of lower craniectomy/craniotomy rate (7.1 % vs 12.7 %, p < 0.002). CONCLUSION In patients with severe TBI, REBOA use is associated with an increased risk of in-hospital mortality, AKI, and infectious complications.
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Affiliation(s)
- Yu Cheng Chiu
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA; Department of General Surgery, Tri-Service General Hospital, Taiwan.
| | - Morihiro Katsura
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA.
| | - Kyosuke Takahashi
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA.
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA.
| | - Demetrios Demetriades
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA.
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Li X, Xie N, Zhou T, Yang B. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Field Setting: A Case Report From China. J Trauma Nurs 2024; 31:272-277. [PMID: 39250556 DOI: 10.1097/jtn.0000000000000803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND The widespread use of agricultural machinery in China has increased the incidence of agricultural machinery-related injuries, posing challenges to on-site medical rescue. This study explores resuscitative endovascular balloon occlusion of the aorta (REBOA) as a life-saving intervention for a patient with severe trauma from agricultural machinery. CASEPRESENTATION This study reviews the emergency medical response for a 70-year-old male who suffered machinery entanglement injuries in an agricultural field in western China. The intervention involved a tiered multidisciplinary medical response, including the implementation of REBOA. CONCLUSION This case demonstrates the successful use of REBOA in the prehospital setting in China. While prehospital REBOA use is rare, it is increasingly reported in both military and civilian contexts in austere environments in different countries. Further research is required to validate the feasibility and efficacy of REBOA as a prehospital resuscitation strategy.
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Affiliation(s)
- Xixi Li
- Author Affiliations: Department of Nursing, Suining Central Hospital, Suining, Sichuan Province, China (Li, Xie, and Zhou); and Emergency Center, Suining Central Hospital, Suining, Sichuan Province, China (Yang)
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Jansen JO, Hudson J, Kennedy C, Cochran C, MacLennan G, Gillies K, Lendrum R, Sadek S, Boyers D, Ferry G, Lawrie L, Nath M, Cotton S, Wileman S, Forrest M, Brohi K, Harris T, Lecky F, Moran C, Morrison JJ, Norrie J, Paterson A, Tai N, Welch N, Campbell MK. The UK resuscitative endovascular balloon occlusion of the aorta in trauma patients with life-threatening torso haemorrhage: the (UK-REBOA) multicentre RCT. Health Technol Assess 2024; 28:1-122. [PMID: 39259521 PMCID: PMC11418015 DOI: 10.3310/ltyv4082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024] Open
Abstract
Background The most common cause of preventable death after injury is haemorrhage. Resuscitative endovascular balloon occlusion of the aorta is intended to provide earlier, temporary haemorrhage control, to facilitate transfer to an operating theatre or interventional radiology suite for definitive haemostasis. Objective To compare standard care plus resuscitative endovascular balloon occlusion of the aorta versus standard care in patients with exsanguinating haemorrhage in the emergency department. Design Pragmatic, multicentre, Bayesian, group-sequential, registry-enabled, open-label, parallel-group randomised controlled trial to determine the clinical and cost-effectiveness of standard care plus resuscitative endovascular balloon occlusion of the aorta, compared to standard care alone. Setting United Kingdom Major Trauma Centres. Participants Trauma patients aged 16 years or older with confirmed or suspected life-threatening torso haemorrhage deemed amenable to adjunctive treatment with resuscitative endovascular balloon occlusion of the aorta. Interventions Participants were randomly assigned 1 : 1 to: standard care, as expected in a major trauma centre standard care plus resuscitative endovascular balloon occlusion of the aorta. Main outcome measures Primary: Mortality at 90 days. Secondary: Mortality at 6 months, while in hospital, and within 24, 6 and 3 hours; need for haemorrhage control procedures, time to commencement of haemorrhage procedure, complications, length of stay (hospital and intensive care unit-free days), blood product use. Health economic: Expected United Kingdom National Health Service perspective costs, life-years and quality-adjusted life-years, modelled over a lifetime horizon. Data sources Case report forms, Trauma Audit and Research Network registry, NHS Digital (Hospital Episode Statistics and Office of National Statistics data). Results Ninety patients were enrolled: 46 were randomised to standard care plus resuscitative endovascular balloon occlusion of the aorta and 44 to standard care. Mortality at 90 days was higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group (54%) compared to the standard care group (42%). The odds ratio was 1.58 (95% credible interval 0.72 to 3.52). The posterior probability of an odds ratio > 1 (indicating increased odds of death with resuscitative endovascular balloon occlusion of the aorta) was 86.9%. The overall effect did not change when an enthusiastic prior was used or when the estimate was adjusted for baseline characteristics. For the secondary outcomes (3, 6 and 24 hours mortality), the posterior probability that standard care plus resuscitative endovascular balloon occlusion of the aorta was harmful was higher than for the primary outcome. Additional analyses to account for intercurrent events did not change the direction of the estimate for mortality at any time point. Death due to haemorrhage was more common in the standard care plus resuscitative endovascular balloon occlusion of the aorta group than in the standard care group. There were no serious adverse device effects. Resuscitative endovascular balloon occlusion of the aorta is less costly (probability 99%), due to the competing mortality risk but also substantially less effective in terms of lifetime quality-adjusted life-years (probability 91%). Limitations The size of the study reflects the relative infrequency of exsanguinating traumatic haemorrhage in the United Kingdom. There were some baseline imbalances between groups, but adjusted analyses had little effect on the estimates. Conclusions This is the first randomised trial of the addition of resuscitative endovascular balloon occlusion of the aorta to standard care in the management of exsanguinating haemorrhage. All the analyses suggest that a strategy of standard care plus resuscitative endovascular balloon occlusion of the aorta is potentially harmful. Future work The role (if any) of resuscitative endovascular balloon occlusion of the aorta in the pre-hospital setting remains unclear. Further research to clarify its potential (or not) may be required. Trial registration This trial is registered as ISRCTN16184981. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/199/09) and is published in full in Health Technology Assessment; Vol. 28, No. 54. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Jan O Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Division of Trauma and Acute Care Surgery, Department of Surgery, The University of Alabama at Birmingham, Birmingham, USA
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gillian Ferry
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mintu Nath
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Karim Brohi
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | | | | | | | - Nick Welch
- Patient and Public Involvement Representative, London, UK
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Powell E, Keller AP, Galvagno SM. Advanced Critical Care Techniques in the Field. Crit Care Clin 2024; 40:463-480. [PMID: 38796221 DOI: 10.1016/j.ccc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.
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Affiliation(s)
- Elizabeth Powell
- Program in Trauma, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Alex P Keller
- Medical Modernization and Plans Division, 162 Dodd Boulevard, Langley Air Force Base, VA 23665, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene Street, S11C16, Baltimore, MD 21201, USA.
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Taheri BD, Fisher AD, Eisenhauer IF, April MD, Rizzo JA, Guliani SS, Flarity KM, Cripps M, Bebarta VS, Wohlauer MV, Schauer SG. The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings. Transfusion 2024; 64 Suppl 2:S19-S26. [PMID: 38581267 DOI: 10.1111/trf.17823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/17/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings. STUDY DESIGN AND METHODS We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use. RESULTS We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge. DISCUSSION We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.
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Affiliation(s)
- Branson D Taheri
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Air Education and Training Command, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio, USA
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas Army National Guard, Austin, Texas, USA
| | - Ian F Eisenhauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Emergency Medicine, Denver Health, Denver, Colorado, USA
- Navy Medicine Leader and Professional Development Command, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 14th Field Hospital, Fort Stewart, Georgia, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Brooke Army Medical Center, JBSA, Fort Sam Houston, Texas, USA
| | - Sundeep S Guliani
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Kathleen M Flarity
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael Cripps
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vikhyat S Bebarta
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Max V Wohlauer
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven G Schauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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6
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Stensæth KH, Carlsen MIS, Løvvik TS, Uleberg O, Brede JR, Søvik E. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjunct treatment in life threatening postpartum hemorrhage: Fourteen years' experience from a single Norwegian center. Acta Obstet Gynecol Scand 2024; 103:965-969. [PMID: 38197478 PMCID: PMC11019522 DOI: 10.1111/aogs.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) remains a global health problem. The introduction of resuscitative endovascular balloon occlusion of the aorta (REBOA) in 2008 sought to enhance the management of hemorrhagic shock during PPH. In this study, we present a single Norwegian center's experience with REBOA as a supportive treatment in combating life threatening PPH. MATERIAL AND METHODS This is a historical cohort study from St Olav's University Hospital, with data from period 2008-2021. It includes all patients who underwent REBOA as an adjunct treatment due to life threatening PPH, analyzing the outcomes and trends over a 14-year period. RESULTS A total of 37 patients received REBOA as an adjunct treatment. All procedures were technically successful, achieving hemodynamic stability with an immediate average increase in systolic blood pressure of 36 ± 22 mmHg upon initial balloon inflation. Additionally, a downward trend was noted in the frequency of hysterectomies and the volume of blood transfusions required over time. No thromboembolic complications were observed. CONCLUSIONS Our 14 years of experience at St Olav's Hospital suggests that REBOA serves as a safe and effective adjunct interventional technique for managing life-threatening PPH. Furthermore, the findings indicate that incorporating a multidisciplinary approach to enable rapid aortic occlusion can potentially reduce the necessity for blood transfusions and hysterectomies.
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Affiliation(s)
- Knut Haakon Stensæth
- Department of Radiology and Nuclear MedicineSt Olav's University HospitalTrondheimNorway
- Department of Circulation and Medical ImagingNorwegian University of Science and TechnologyTrondheimNorway
| | - Marte Irene Skille Carlsen
- Department of Anesthesiology and Intensive Care MedicineSt Olav's University HospitalTrondheimNorway
- Department of TraumatologySt. Olav's University HospitalTrondheimNorway
| | - Tone Shetelig Løvvik
- Department of Obstetrics and GynecologySt Olav's University HospitalTrondheimNorway
| | - Oddvar Uleberg
- Department of Emergency Medicine and Pre‐hospital ServicesSt Olav's University HospitalTrondheimNorway
- Department of Research and Development, Division of Emergencies and Critical CareOslo University HospitalOsloNorway
| | - Jostein Rødseth Brede
- Department of Anesthesiology and Intensive Care MedicineSt Olav's University HospitalTrondheimNorway
- Department of Emergency Medicine and Pre‐hospital ServicesSt Olav's University HospitalTrondheimNorway
- Department of Research and DevelopmentNorwegian Air Ambulance FoundationOsloNorway
| | - Edmund Søvik
- Department of Radiology and Nuclear MedicineSt Olav's University HospitalTrondheimNorway
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Alremeithi R, Tran QK, Quintana MT, Shahamatdar S, Pourmand A. Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers. World J Emerg Med 2024; 15:3-9. [PMID: 38188559 PMCID: PMC10765073 DOI: 10.5847/wjem.j.1920-8642.2023.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/28/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA. METHODS We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process. RESULTS A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS. CONCLUSION TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.
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Affiliation(s)
- Rashed Alremeithi
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Quincy K. Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore 21201, USA
- Program in Trauma, the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore 21201, USA
| | - Megan T. Quintana
- Center for Trauma and Critical Care, Department of Surgery, the George Washington University School of Medicine & Health Sciences, Washington DC 20037, USA
| | - Soroush Shahamatdar
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
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Marsden M, Lendrum R, Davenport R. Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta. Curr Opin Crit Care 2023; 29:689-695. [PMID: 37861182 DOI: 10.1097/mcc.0000000000001106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to temporarily control bleeding and improve central perfusion in critically injured trauma patients remains a controversial topic. In the last decade, select trauma services around the world have gained experience with REBOA. We discuss the recent observational data together with the initial results of the first randomized control trial and provide a view on the next steps for REBOA in trauma resuscitation. RECENT FINDINGS While the observational data continue to be conflicting, the first randomized control trial signals that in the UK, in-hospital REBOA is associated with harm. Likely a result of delays to haemorrhage control, views are again split on whether to abandon complex interventions in bleeding trauma patients and to only prioritize transfer to the operating room or to push REBOA earlier into the post injury phase, recognizing that some patients will not survive without intervention. SUMMARY Better understanding of cardiac shock physiology provides a new lens in which to evaluate REBOA through. Patient selection remains a huge challenge. Invasive blood pressure monitoring, combined with machine learning aided decision support may assist clinicians and their patients in the future. The use of REBOA should not delay definitive haemorrhage control in those patients without impending cardiac arrest.
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Affiliation(s)
- Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- Academic Department of Military Surgery and Trauma, Research and Clinical Innovation, Birmingham
| | - Robert Lendrum
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- London's Air Ambulance
- Department of Perioperative Medicine, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
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Jansen JO, Hudson J, Cochran C, MacLennan G, Lendrum R, Sadek S, Gillies K, Cotton S, Kennedy C, Boyers D, Ferry G, Lawrie L, Nath M, Wileman S, Forrest M, Brohi K, Harris T, Lecky F, Moran C, Morrison JJ, Norrie J, Paterson A, Tai N, Welch N, Campbell MK. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA 2023; 330:1862-1871. [PMID: 37824132 PMCID: PMC10570916 DOI: 10.1001/jama.2023.20850] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/23/2023] [Indexed: 10/13/2023]
Abstract
Importance Bleeding is the most common cause of preventable death after trauma. Objective To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage. Design, Setting, and Participants Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days. Intervention Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44). Main Outcomes and Measures The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death. Results Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours. Conclusions and Relevance In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone. Trial Registration isrctn.org Identifier: ISRCTN16184981.
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Affiliation(s)
- Jan O. Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
- Center for Injury Science, University of Alabama at Birmingham
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Sam Sadek
- Royal London Hospital, London, England
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Gillian Ferry
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mintu Nath
- Medical Statistics Team, University of Aberdeen, Aberdeen, Scotland
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Karim Brohi
- Queen Mary University of London, London, England
| | - Tim Harris
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Chris Moran
- Nottingham University Hospital Trust, Nottingham, England
| | - Jonathan J. Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland
| | | | - Nigel Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England
| | - Nick Welch
- Patient and public involvement representative in England
| | - Marion K. Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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Manning JE, Morrison JJ, Pepe PE. Prehospital Resuscitation: What Should It Be? Adv Surg 2023; 57:233-256. [PMID: 37536856 DOI: 10.1016/j.yasu.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.
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Affiliation(s)
- James E Manning
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Paul E Pepe
- University of Miami, Miller School of Medicine, Miami, FL, USA; Dallas County Public Safety, Emergency Medical Services, Dallas, TX, USA; Global Emergency Medical Services, Suite 307 Point of Americas One, 2100 South Ocean Lane, Fort Lauderdale, FL 33316-3823, USA
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11
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Extremity tourniquets raise blood pressure and maintain heart rate. Am J Emerg Med 2023; 65:12-15. [PMID: 36577207 DOI: 10.1016/j.ajem.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/04/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Tourniquets have been modified and used for centuries to occlude blood flow to control hemorrhage. More recently, the occlusion of peripheral vessels has been linked to resultant increases in blood pressure, which may provide additional therapeutic potential, particularly during states of low cardiac output. OBJECTIVE The objective of this study was to investigate a causal relationship between tourniquet application and blood pressure in healthy adults. METHODS Healthy adult volunteers were recruited to participate in this IRB-approved study. Each participant met inclusion criteria and demonstrated baseline normotension. Brachial cuff blood pressure and heart rate were recorded pre- and post-tourniquet application to the bilateral legs. RESULTS Twenty-seven adults aged 22 to 35 years participated and were included in analysis. The average systolic blood pressure was 122 ± 7 mmHg, diastolic blood pressure was 72 ± 9 mmHg, and heart rate was 70 ± 13 bpm. Following bilateral tourniquet application over the femoral vasculature, we observed a statistically significant increase in systolic (7 mmHg, p < 0.001) and diastolic (4 mmHg, p = 0.05) blood pressures with no significant change in heart rate (2 bpm, p > 0.05). CONCLUSIONS The elevations in systolic and diastolic blood pressures establish a dependent relationship between tourniquet application to the lower extremities and blood pressure elevation. These results may support new indications for tourniquet-use or extremity vessel occlusion in settings of hemodynamic instability.
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Kenawy DM, Elsisy M, Abdel-Rasoul M, Koppert TL, Garcia-Neuer MI, Chun Y, Tillman BW. A dumbbell rescue stent graft facilitates clamp-free repair of aortic injury in a porcine model. JVS Vasc Sci 2023; 4:100100. [PMID: 37021144 PMCID: PMC10068254 DOI: 10.1016/j.jvssci.2023.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/01/2023] [Indexed: 02/19/2023] Open
Abstract
Objective Noncompressible torso hemorrhage is a high-mortality injury. We previously reported improved outcomes with a retrievable rescue stent graft to temporize aortic hemorrhage in a porcine model while maintaining distal perfusion. A limitation was that the original cylindrical stent graft design prohibited simultaneous vascular repair, given the concern for suture ensnarement of the temporary stent. We hypothesized that a modified, dumbbell-shaped design would preserve distal perfusion and also offer a bloodless plane in the midsection, facilitating repair with the stent graft in place and improve the postrepair hemodynamics. Methods In an Institutional Animal Care and Use Committee-approved terminal porcine model, a custom retrievable dumbbell-shaped rescue stent graft (dRS) was fashioned from laser-cut nitinol and polytetrafluoroethylene covering and compared with aortic cross-clamping. Under anesthesia, the descending thoracic aorta was injured and then repaired with cross-clamping (n = 6) or dRS (n = 6). Angiography was performed in both groups. Operations were divided into phases: (1) baseline, (2) thoracic injury with either cross-clamp or dRS deployed, and (3) recovery, after which the clamp or dRS were removed. Target blood loss was 22% to simulate class II or III hemorrhagic shock. Shed blood was recovered with a Cell Saver and reinfused for resuscitation. Renal artery flow rates were recorded at baseline and during the repair phase and reported as a percentage of cardiac output. Phenylephrine pressor requirements were recorded. Results In contrast with cross-clamped animals, dRS animals demonstrated both operative hemostasis and preserved flow beyond the dRS angiographically. Recovery phase mean arterial pressure, cardiac output, and right ventricular end-diastolic volume were significantly higher in dRS animals (P = .033, P = .015, and P = .012, respectively). Whereas distal femoral blood pressures were absent during cross-clamping, among the dRS animals, the carotid and femoral MAPs were not significantly different during the injury phase (P = .504). Cross-clamped animals demonstrated nearly absent renal artery flow, in contrast with dRS animals, which exhibited preserved perfusion (P<.0001). Femoral oxygen levels (partial pressure of oxygen) among a subset of animals further confirmed greater distal oxygenation during dRS deployment compared with cross-clamping (P = .006). After aortic repair and clamp or stent removal, cross-clamped animals demonstrated more significant hypotension, as demonstrated by increased pressor requirements over stented animals (P = .035). Conclusions Compared with aortic cross-clamping, the dRS model demonstrated superior distal perfusion, while also facilitating simultaneous hemorrhage control and aortic repair. This study demonstrates a promising alternative to aortic cross-clamping to decrease distal ischemia and avoid the unfavorable hemodynamics that accompany clamp reperfusion. Future studies will assess differences in ischemic injury and physiological outcomes. Clinical Relevance Noncompressible aortic hemorrhage remains a high-mortality injury, and current damage control options are limited by ischemic complications. We have previously reported a retrievable stent graft to allow rapid hemorrhage control, preserved distal perfusion, and removal at the primary repair. The prior cylindrical stent graft was limited by the inability to suture the aorta over the stent graft owing to risk of ensnarement. This large animal study explored a dumbbell retrievable stent with a bloodless plane to allow suture placement with the stent in place. This approach improved distal perfusion and hemodynamics over clamp repair and heralds the potential for aortic repair while avoiding complications.
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Affiliation(s)
- Dahlia M. Kenawy
- Division of Vascular Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Moataz Elsisy
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Tanner L. Koppert
- Division of Vascular Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Youngjae Chun
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Bryan W. Tillman
- Division of Vascular Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Qasim Z. Resuscitative Endovascular Balloon Occlusion of the Aorta. Emerg Med Clin North Am 2023; 41:71-88. [DOI: 10.1016/j.emc.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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14
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Pollock GA, Lo J, Chou H, Kissen MS, Kim M, Zhang V, Betz A, Perlman R. Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review. Br J Anaesth 2023; 130:e80-e91. [PMID: 36096943 DOI: 10.1016/j.bja.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/27/2022] [Accepted: 07/02/2022] [Indexed: 01/06/2023] Open
Abstract
Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.
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Affiliation(s)
- Gabriel A Pollock
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jessie Lo
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Henry Chou
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael S Kissen
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle Kim
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vida Zhang
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Betz
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ryan Perlman
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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15
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Ko HJ, Koo HF, Al-Saadi N, Froghi S. A comparison of mortality and indicators of treatment success of resuscitative endovascular balloon occlusion of aorta (REBOA): a systematic review and meta-analysis. Indian J Thorac Cardiovasc Surg 2023; 39:27-36. [PMID: 36590045 PMCID: PMC9794671 DOI: 10.1007/s12055-022-01413-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022] Open
Abstract
Background Emergency resuscitative thoracotomy (RT) is a recognised method of controlling non-compressible torso haemorrhage (NCTH) often in adjunct to emergency surgery. Recently, there is much debate regarding resuscitative endovascular balloon occlusion of aorta (REBOA) on its role in civilian trauma cases in controlling NCTH. This study aims to provide an updated review on in-hospital mortality rates in patients who underwent REBOA versus RT and standard care without REBOA (non-REBOA) and to identify the potential indicators of REBOA survival. Methods Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to perform the study. All adult trauma cases were included, while pre-hospital, military and non-English studies were excluded. A literature search was done on studies from 01 January 2005 to 30 June 2020 using EMBASE, MEDLINE and COCHRANE databases. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. Meta-analysis was conducted using a random effects model and the DerSimonian and Laird estimation method. A significance level of p < 0.05 was used. Results Twenty-five studies were included in this study. The odds of in-hospital mortality of patients who underwent REBOA compared to RT was 0.18 (p < 0.01, 0.12-0.26). The odds of in-hospital survival of patients who underwent REBOA compared to non-REBOA was 1.28 (p = 0.62, 0.46-3.53). There was a significant difference found between survivors and non-survivors in terms of their pre-REBOA systolic blood pressure (SBP) (19.26 mmHg, p < 0.01), post-REBOA SBP (20.73 mmHg, p < 0.01), duration of aortic occlusion (- 40.57 min, p < 0.01) and injury severity score (- 8.50, p < 0.01). Conclusions REBOA has a potential for wider application in civilian settings, with our study demonstrating lower in-hospital mortality compared to RT. Prospective multi-centre studies are needed for further evaluation of the indications and feasibility of REBOA.Level of Evidence + Study Type: Level IV. Systematic review with meta-analysis. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-022-01413-3.
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Affiliation(s)
- Ho Juen Ko
- University College London, London, UK
- Department of HPB & Liver Transplantation, Division of Surgery & Interventional Sciences, Royal Free Hospital, Pond Street, Hampstead, NW2 2QG London UK
| | | | - Nina Al-Saadi
- Vascular Surgery Glenfield Hospital UHL NHS Trust, Leicester, UK
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16
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Maiga AW, Kundi R, Morrison JJ, Spalding C, Duchesne J, Hunt J, Nguyen J, Benjamin E, Moore EE, Lawless R, Beckett A, Russo R, Dennis BM. Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection. Trauma Surg Acute Care Open 2022; 7:e000984. [PMID: 36578977 PMCID: PMC9791466 DOI: 10.1136/tsaco-2022-000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized. Results Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control. Conclusion Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments. Level of evidence Level 5, systematic review.
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Affiliation(s)
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | | | | | - Juan Duchesne
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - John Hunt
- University Medical Center New Orleans, New Orleans, Louisiana, USA
| | - Jonathan Nguyen
- Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | | | | | - Ryan Lawless
- Denver Health Medical Center, Denver, Colorado, USA
| | | | - Rachel Russo
- University of California Davis Medical Center, Sacramento, California, USA
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17
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Chavez MA, Weinberg JA, Jacobs JV, Soe-Lin H, Chapple KM, Ryder M, Conley I, Bogert JN. Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy. Am J Surg 2022; 224:1464-1467. [PMID: 35623945 DOI: 10.1016/j.amjsurg.2022.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/06/2022] [Accepted: 04/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature. METHODS Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded. RESULTS The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications. CONCLUSION Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.
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Affiliation(s)
- Marin A Chavez
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan A Weinberg
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan V Jacobs
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Hahn Soe-Lin
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Kristina M Chapple
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Madison Ryder
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - Ian Conley
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - James N Bogert
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States.
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Valisena S, Abboud AE, Andereggen E, Ansorge A, Gamulin A. Management of high-energy blunt pelvic ring injuries: A retrospective cohort study evaluating an institutional protocol. Injury 2022; 53:4054-4061. [PMID: 36195515 DOI: 10.1016/j.injury.2022.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/05/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION High-energy blunt pelvic ring injuries with hemodynamic instability are complicated by a high mortality rate (up to 32%). There is no consensus on the best management strategy for these injuries. The aim of this study was to evaluate the high-energy blunt pelvic ring injury management protocol implemented in the authors' institution. PATIENTS AND METHODS This retrospective cohort study was performed in an academic level I trauma center. The institutional protocol incorporates urgent pelvic mechanical stabilization of hemodynamically unstable patients not responding to a pelvic belt, fluids, and transfusions. If hemodynamic instability persists, angiography ± embolization is performed. Adult patients sustaining a high-energy blunt pelvic ring injury between 2014.01.01 and 2019.12.31 were included in the study. The primary outcome was mortality at 1, 2, 30 and 60 days. The secondary outcomes were the number of packed red blood cell units transfused during the first 24 h, intensive care unit stay, and total hospitalization length of stay. RESULTS 192 high-energy blunt pelvic ring injury patients were analyzed. Of these, 71 (37%) were hemodynamically unstable, and 121 (63%) were stable. The overall in-hospital mortality of the hemodynamically unstable and stable groups was 20/71 (28.2%) and 4/121 (3.3%) respectively (p<0.001). Cumulative mortality rates for hemodynamically unstable patients were 15.5% at day 1, 16.9% at day 2, 26.8% at day 30 and 28.2% at day 60, and for hemodynamically stable patients, rates were 0% at day 1 and 2, 2.5% at day 30 and 3.3% at day 60. Unstable patients required a higher number of packed red blood cell units than stable patients during the first 24 h (5.1 vs. 0.1; p<0.001). Intensive care unit length of stay and total hospitalization duration was 11.25 and 37.4 days for unstable patients and 1.9 and 20.9 days for stable patients (p<0.001). CONCLUSIONS For both hemodynamically unstable and stable patients, the institutional protocol showed favorable mortality rates when compared to available literature. Comparative studies are needed to determine the management strategies with the best clinical outcome and survival.
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Affiliation(s)
- Silvia Valisena
- Division of Orthopaedic and Trauma Surgery, University Hospitals of Geneva, 4 Rue Gabrielle-Perret-Gentil, CH-1205 Geneva, Switzerland.
| | - Anna-Eliane Abboud
- Division of Orthopaedic and Trauma Surgery, University Hospitals of Geneva, 4 Rue Gabrielle-Perret-Gentil, CH-1205 Geneva, Switzerland
| | - Elisabeth Andereggen
- Division of Emergency Medicine, University Hospitals of Geneva, 4 Rue Gabrielle-Perret-Gentil, CH-1205 Geneva, Switzerland
| | - Alexandre Ansorge
- Division of Orthopaedic and Trauma Surgery, University Hospitals of Geneva, 4 Rue Gabrielle-Perret-Gentil, CH-1205 Geneva, Switzerland
| | - Axel Gamulin
- Division of Orthopaedic and Trauma Surgery, University Hospitals of Geneva, 4 Rue Gabrielle-Perret-Gentil, CH-1205 Geneva, Switzerland
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Slot SAS, van Oostendorp SE, Schoonmade LJ, Geeraedts LMG. The role of REBOA in patients in traumatic cardiac arrest subsequent to hemorrhagic shock: a scoping review. Eur J Trauma Emerg Surg 2022; 49:693-707. [PMID: 36335515 PMCID: PMC10175493 DOI: 10.1007/s00068-022-02154-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022]
Abstract
Abstract
Purpose
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a useful adjunct in treatment of patients in severe hemorrhagic shock. Hypothetically, REBOA could benefit patients in traumatic cardiac arrest (TCA) as balloon occlusion of the aorta increases afterload and may improve myocardial performance leading to return of spontaneous circulation (ROSC). This scoping review was conducted to examine the effect of REBOA on patients in TCA.
Methods
This scoping review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) Statement. PubMed, EMBASE.com and the Web of Science Core Collection were searched. Articles were included if they reported any data on patients that underwent REBOA and were in TCA. Of the included articles, data regarding SBP, ROSC and survival were extracted and summarized.
Results
Of 854 identified studies, 26 articles met criteria for inclusion. These identified a total of 785 patients in TCA that received REBOA (presumably less because of potential overlap in patients). This review shows REBOA elevates mean SBP in patients in TCA. The achievement of ROSC after REBOA deployment ranged from 18.2% to 67.7%. Survival to discharge ranged from 3.5% to 12.1%.
Conclusion
Overall, weak evidence is available on the use of REBOA in patients in TCA. This review, limited by selection bias, indicates that REBOA elevates SBP and may benefit ROSC and potentially survival to discharge in patients in TCA. Extensive further research is necessary to further clarify the role of REBOA during TCA.
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Werner NL, Moore EE, Hoehn M, Lawless R, Coleman JR, Freedberg M, Heelan AA, Platnick KB, Cohen MJ, Coleman JJ, Campion EM, Fox CJ, Mauffrey C, Cralley A, Pieracci FM, Burlew CC. Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury 2022; 53:3365-3370. [PMID: 36038388 DOI: 10.1016/j.injury.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
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Affiliation(s)
- Nicole L Werner
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America.
| | - Ernest E Moore
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Melanie Hoehn
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Ryan Lawless
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Julia R Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mari Freedberg
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alicia A Heelan
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - K Barry Platnick
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mitchell J Cohen
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Jamie J Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Eric M Campion
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Charles J Fox
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Cyril Mauffrey
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alexis Cralley
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Fredric M Pieracci
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Clay Cothren Burlew
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
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Aoki M, Abe T. Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta. Front Med (Lausanne) 2022; 9:888225. [PMID: 35783650 PMCID: PMC9243328 DOI: 10.3389/fmed.2022.888225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/26/2022] [Indexed: 12/05/2022] Open
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
- *Correspondence: Makoto Aoki
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
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Reich CF, Levy NA, Beal MW. Evaluation of resuscitative endovascular balloon occlusion of the aorta catheter placement and comparison to resuscitative thoracotomy with aortic clamping in cadaver dogs. J Vet Emerg Crit Care (San Antonio) 2022; 32:623-628. [PMID: 35687424 DOI: 10.1111/vec.13197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/03/2021] [Accepted: 01/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe placement of an aortic occlusion catheter in aortic zone 1 (Z1) and aortic zone 3 (Z3) in dogs and to compare time to placement in these zones with and without external chest compressions (ECC). Additional evaluations of time to placement in Z1 with time for resuscitative thoracotomy with aortic clamping (RT-AC) were performed. DESIGN Prospective ex vivo study. SETTING University teaching hospital. ANIMALS Ten canine cadavers. INTERVENTIONS Ten cadaver dogs were obtained from client donation after euthanasia. Cadavers were randomized to have balloon catheter placement into the right or left femoral artery via cutdown, with or without ECC. The xiphoid was used as an external anatomical landmark for Z1, and the spinous process of the 5th lumbar vertebra was used for Z3. Balloon placement was confirmed with radiography. Time to balloon placement in Z1 and Z3 and time to RT-AC were recorded. MEASUREMENTS AND MAIN RESULTS Median body weight was 23.5 kg (9-40 kg). Median time to Z1 placement was 6.6 minutes (4.6-12.4 minutes) with ECC and 6.9 minutes (3.3-13.1 minutes) without ECC and was not statistically different (P = 0.5). Median time to RT-AC was 1 minute (0.6-1.4 minutes), which was significantly faster than time to balloon placement in Z1 with or without ECC (P = 0.004 and P = 0.002, respectively). CONCLUSIONS Endovascular balloon occlusion of the aorta can be achieved by cutdown with and without ECC, but RT-AC is faster. Successful balloon position in Z1 could be achieved with knowledge of external anatomical landmarks, but landmarks for Z3 need further study.
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Affiliation(s)
- Colin F Reich
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Nyssa A Levy
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Matthew W Beal
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
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Jansen JO, Cochran C, Boyers D, Gillies K, Lendrum R, Sadek S, Lecky F, MacLennan G, Campbell MK. The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial). Trials 2022; 23:384. [PMID: 35550642 PMCID: PMC9097076 DOI: 10.1186/s13063-022-06346-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury. METHODS Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective. DISCUSSION This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice. TRIAL REGISTRATION ISRCTN16184981.
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Affiliation(s)
- Jan O Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
- Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, 35294, USA.
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Sam Sadek
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Schellenberg M, Owattanapanich N, DuBose JJ, Brenner M, Magee GA, Moore LJ, Scalea T, Inaba K. Resuscitative Endovascular Balloon Occlusion of the Aorta in Penetrating Trauma. J Am Coll Surg 2022; 234:872-880. [PMID: 35426399 DOI: 10.1097/xcs.0000000000000136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control via aortic occlusion. Existing REBOA literature focuses on blunt trauma without a clearly defined role in penetrating trauma. This study compared clinical/injury data and outcomes after REBOA in penetrating vs blunt trauma. STUDY DESIGN All patients in the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) database, an observational American Association for the Surgery of Trauma dataset of trauma patients requiring aortic occlusion, who underwent REBOA were included (January 2014 through February 2021). Study groups were defined by mechanism: penetrating vs blunt. Subgroup analysis was performed of patients arriving with vital signs. Univariable/multivariable analyses compared injuries and outcomes. RESULTS Seven hundred fifty-nine patients underwent REBOA: 152 (20%) penetrating and 607 (80%) blunt. Patients undergoing penetrating REBOA were less severely injured (injury severity score 25 vs 34; p < 0.001). The most common hemorrhage source was abdominal in penetrating REBOA (79%) and pelvic in blunt REBOA (31%; p = 0.002). Penetrating REBOA was more likely to occur in the operating room (36% vs 17%) and less likely in the emergency department (63% vs 81%; p < 0.001). Penetrating REBOA used more zone I balloon deployment (76% vs 64%) and less zone III (19% vs 34%; p = 0.001). Improved or stabilized hemodynamics were less frequent after penetrating REBOA (41% vs 62%, p < 0.001; 23% vs 41%, p < 0.001). On subgroup analysis of patients arriving alive, improvement or stabilization in hemodynamics was similar between groups (87% vs 86%, p = 0.388; 77% vs 72%, p = 0.273). Penetrating REBOA was not independently associated with mortality (odds ratio 1.253; p = 0.776). CONCLUSIONS Despite lower injury severity, REBOA was significantly less likely to improve or stabilize hemodynamics after penetrating trauma. Among patients arriving alive, however, outcomes were comparable, suggesting that penetrating REBOA may be most beneficial among patients with vital signs. Because hemorrhage source, catheter insertion setting, and deployment zone varied significantly between groups, existing blunt REBOA data may not be appropriately extrapolated to penetrating trauma. Further study of REBOA as a means of aortic occlusion in penetrating trauma is needed.
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Affiliation(s)
- Morgan Schellenberg
- From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Schellenberg, Owattanapanich, Magee, Inaba)
| | - Natthida Owattanapanich
- From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Schellenberg, Owattanapanich, Magee, Inaba)
| | - Joseph J DuBose
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (DuBose, Scalea)
| | - Megan Brenner
- Department of Surgery, University of California Riverside Medical Center, Riverside, CA (Brenner)
| | - Gregory A Magee
- From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Schellenberg, Owattanapanich, Magee, Inaba)
| | - Laura J Moore
- Department of Surgery, The University of Texas Health Sciences Center at Houston, Houston, TX (Moore)
| | - Thomas Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (DuBose, Scalea)
| | - Kenji Inaba
- From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Schellenberg, Owattanapanich, Magee, Inaba)
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Yamamoto R, Alarhayem A, Muir MT, Jenkins DH, Eastridge BJ, Shapiro ML, Cestero RF. Gaining or wasting time? Influence of time to operating room on mortality after temporary hemostasis using resuscitative endovascular balloon occlusion of the aorta. Am J Surg 2022; 224:125-130. [DOI: 10.1016/j.amjsurg.2022.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 01/24/2022] [Accepted: 03/31/2022] [Indexed: 11/01/2022]
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Laverty RB, Treffalls RN, McEntire SE, DuBose JJ, Morrison JJ, Scalea TM, Moore LJ, Podbielski JM, Inaba K, Piccinini A, Kauvar DS. Life over limb: Arterial access-related limb ischemic complications in 48-hour REBOA survivors. J Trauma Acute Care Surg 2022; 92:723-728. [PMID: 34789696 DOI: 10.1097/ta.0000000000003440] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used in some trauma settings. Arterial access-related limb ischemic complications (ARLICs) resulting from the femoral arterial access required for REBOA are largely under reported. We sought to describe the incidence of these complications and the clinical, technical, and device factors associated with their development. METHODS This was a retrospective cohort study of records of adult trauma patients from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between October 2013 and September 2020 who had REBOA and survived at least 48 hours. The primary outcome was ARLIC, defined as clinically relevant extremity ischemia or distal embolization. Relevant factors associated with ARLIC were also analyzed. RESULTS Of 418 identified patients, 36 (8.6%) sustained at least one ARLIC; 22 with extremity ischemia, 25 with distal embolism, 11 with both. Patient demographics and injury characteristics were similar between ARLIC and no ARLIC groups. Access-related limb ischemic complication was associated with larger profile devices (p = 0.009), cutdown access technique (p = 0.02), and the presence of a pelvic external fixator/binder (p = 0.01). Patients with ARLIC had higher base deficit (p = 0.03) and lactate (p = 0.006). One hundred fifty-six patients received tranexamic acid (TXA), with 22 (14%) ARLICs. The rate of TXA use among ARLIC patients was 61% (vs. 35% TXA for non-ARLIC patients, p = 0.002). Access-related limb ischemic complication did not result in additional in-hospital mortality, however, ARLIC had prolonged hospital LOS (31 vs. 24 days, p = 0.02). Five ARLIC required surgical intervention, three patch angioplasty (and two with associated bypass), and four ARLIC limbs were amputated. CONCLUSION Femoral artery REBOA access carries a risk of ARLIC, which is associated with unstable pelvis fractures, severe shock, and strongly with the administration of TXA. Use of lower-profile devices and close surveillance for these complications is warranted in these settings and caution should be exercised when using TXA in conjunction with REBOA. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level III.
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Affiliation(s)
- Robert B Laverty
- From the Department of Surgery (R.B.L.), Brooke Army Medical Center, JBSA Fort Sam Houston, Houston; Department of Surgery, University of the Incarnate Word School of Medicine (R.N.T.), San Antonio; Department of Surgery, Vascular Surgery Service (S.E.M., D.S.K.), Brooke Army Medical Center, JBSA Fort Sam Houston, Houston, Texas; Department of Surgery, University of Maryland/R Adams Cowley Shock Trauma Center (J.J.D., J.J.M., T.M.S.), Baltimore, Maryland; Department of Surgery, University of Texas Health Sciences Center-Houston (L.J.M., J.M.P.), Houston, Texas; Department of Surgery, Los Angeles County + University of Southern California Hospital (K.I., A.P.), Los Angeles, California; and Department of Surgery (D.S.K.), Uniformed Services University, Bethesda, Maryland
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Moore LJ, Rasmussen TE. A contemporary assessment of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2022; 92:762-764. [PMID: 35121706 DOI: 10.1097/ta.0000000000003556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Laura J Moore
- From the Department of Surgery, University of Texas McGovern Medical School (L.J.M.), Houston, Texas; and Department of Surgery (T.E.R.), Mayo Clinic, Rochester, Minnesota
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Harfouche MN, Madurska MJ, Elansary N, Abdou H, Lang E, DuBose JJ, Kundi R, Feliciano DV, Scalea TM, Morrison JJ. Resuscitative endovascular balloon occlusion of the aorta associated with improved survival in hemorrhagic shock. PLoS One 2022; 17:e0265778. [PMID: 35324991 PMCID: PMC8947416 DOI: 10.1371/journal.pone.0265778] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of trauma patients in shock undergoing REBOA versus no-REBOA. Methods This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000–2019). REBOA (R; 2015–2019) patients were propensity matched 2:1 to historic (H; 2000–2012) and contemporary (C; 2013–2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively. Results A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups. Conclusion In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.
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Affiliation(s)
- Melike N. Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Eric Lang
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Joseph J. DuBose
- Dell Medical School, University of Texas at Austin, Austin, Texas, United States of America
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - David V. Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
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Abstract
Resuscitative endovascular balloon occlusion of the aorta is a tool that can play an important role for the modern-day Trauma Surgeon. Although the concept of aortic balloon occlusion is not new, its use as a rescue device for managing life-threatening traumatic hemorrhage has increased dramatically. The ideal role for resuscitative endovascular balloon occlusion of the aorta continues to evolve. In situations of noncompressible truncal hemorrhage, its use can temporize bleeding while other means of hemorrhage control, including those discussed elsewhere in this supplement, are used. However, it is a tool with potentially significant complications and consequences. Studies examining resuscitative endovascular balloon occlusion of the aorta are ongoing as, despite its ever-increasing adoption, quality evidence to support its clinical use is lacking.
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Affiliation(s)
- Paul M. Cantle
- Peter Lougheed Centre 5th East Wing, 5940-3500 26th Ave NE, Calgary, AB, Canada T1Y 6J4. Tel.: + 1 (403) 943-5474; fax: + 1 (403) 291-2734.
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The Role of Prehospital REBOA for Hemorrhage Control in Civilian and Military Austere Settings: A Systematic Review. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite the success of prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in combat and civilian settings, the prevalence of complications and the lack of conclusive evidence has led to uncertainty and controversy. Therefore, this systematic review aimed to evaluate the role of prehospital REBOA for hemorrhage control in trauma populations. We systematically searched Cochrane, Ovid MEDLINE, EMBASE and Google Scholar for all relevant studies that investigated the efficacy of prehospital REBOA on trauma patients with massive hemorrhage. Primary outcome was evaluated by blood pressure elevation and secondary outcome was measured by 30-day mortality and complications. Our search identified 546 studies, but only six studies met the inclusion and exclusion criteria. Included studies were low to moderate quality due to limitations within the studies. However, all of the studies reported significant elevation of blood pressure and survival, demonstrating the potential benefits of REBOA. For example, the 30-day mortality rate reduced significantly after REBOA, but studies lacked long-term outcome assessments across the continuum of care. Due to the heterogeneity of the results, a meta-analysis was not possible. We conclude that prehospital REBOA is a feasible and effective resuscitative adjunct for shock patients with lethal non-compressible torso hemorrhage. However, due to the unclear causes of complications and the lack of high quality and homogeneous data, the effects of prehospital REBOA were not truly reflected and comparison between groups was not feasible. Thus, further high-quality studies are required to attest the causality between prehospital REBOA and outcomes.
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Gary JL. Commentary on: "Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries". J Orthop Trauma 2022; 36:74. [PMID: 34407036 DOI: 10.1097/bot.0000000000002243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Joshua L Gary
- McGovern Medical School at UTHealth Houston, Houston, TX
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Marchand LS, Sepehri A, Hannan ZD, Zaidi SM, Bangura AT, Morrison JJ, Manson TT, Slobogean GP, O’Hara NN, O’Toole RV. Pelvic Ring Injury Mortality: Are We Getting Better? J Orthop Trauma 2022; 36:81-86. [PMID: 34128497 PMCID: PMC8669037 DOI: 10.1097/bot.0000000000002210] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study. INTERVENTION Pelvic ring management, years 1999-2006 versus years 2007-2018. MAIN OUTCOME MEASUREMENTS In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score. RESULTS The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01). CONCLUSION Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S. Marchand
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aresh Sepehri
- University of British Columbia, Department of Orthopaedic Surgery, Vancouver, BC, Canada
| | - Zachary D. Hannan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Syed M.R. Zaidi
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdulai T. Bangura
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan N. O’Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V. O’Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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The Anchor Point Algorithm. J Trauma Acute Care Surg 2022; 93:488-495. [DOI: 10.1097/ta.0000000000003539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Control of pelvic fracture-related hemorrhage. Surg Open Sci 2022; 8:23-26. [PMID: 35252831 PMCID: PMC8892196 DOI: 10.1016/j.sopen.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/30/2021] [Accepted: 01/18/2022] [Indexed: 11/23/2022] Open
Abstract
This is a paper about pelvic fracture–related bleeding control.
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Abstract
PURPOSE OF REVIEW European Resuscitation Council Guidelines for Cardiopulmonary Resuscitation prioritize treatments like chest compression and defibrillation, known to be highly effective for cardiac arrest from cardiac origin. This review highlights the need to modify this approach in special circumstances. RECENT FINDINGS Potentially reversible causes of cardiac arrest are clustered into four Hs and four Ts (Hypoxia, Hypovolaemia, Hyperkalaemia/other electrolyte disorders, Hypothermia, Thrombosis, Tamponade, Tension pneumothorax, Toxic agents). Point-of-care ultrasound has its role in identification of the cause and targeting treatment. Time-critical interventions may even prevent cardiac arrest if applied early. The extracorporeal CPR (eCPR) or mechanical CPR should be considered for bridging the period needed to reverse the precipitating cause(s). There is low quality of evidence available to guide the treatment in the majority of situations. Some topics (pulmonary embolism, eCPR, drowning, pregnancy and opioid toxicity) were included in recent ILCOR reviews and evidence updates but majority of recommendations is based on individual systematic reviews, scoping reviews, evidence updates and expert consensus. SUMMARY Cardiac arrests from reversible causes happen with lower incidence. Return of spontaneous circulation and neurologically intact survival can hardly be achieved without a modified approach focusing on immediate treatment of the underlying cause(s) of cardiac arrest.
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Thies N, Zech A, Kohlmann T, Biberthaler P, Bayeff-Filloff M, Kanz KG, Prückner S. Preparation of hospitals for mass casualty incidents in Bavaria, Germany: care capacities for penetrating injuries and explosions in TerrorMASCALs. Scand J Trauma Resusc Emerg Med 2021; 29:156. [PMID: 34717723 PMCID: PMC8557545 DOI: 10.1186/s13049-021-00970-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background In a terror attack mass casualty incident (TerrorMASCAL), compared to a “normal” MASCAL, there is a dynamic course that can extend over several hours. The injury patterns are penetrating and perforating injuries. This article addresses the provision of material and personnel for the care of special injuries of severely injured persons that may occur in the context of a TerrorMASCAL. Methods To answer the research question about the preparation of hospitals for the care of severely injured persons in a TerrorMASCAL, a survey of trauma surgery departments in Bavaria (Germany) was conducted using a questionnaire, which was prepared in three defined steps based on an expert consensus. The survey is divided into a general, neurosurgical, thoracic, vascular and trauma surgery section. In the specialized sections, the questions relate to the implementation of and material and personnel requirements for special interventions that are required, particularly for injury patterns following gunshot and explosion injuries, such as trepanation, thoracotomy and balloon occlusion of the aorta. Results In the general section, it was noted that only a few clinics have an automated system to notify off-duty staff. When evaluating the data from the neurosurgical section, the following could be established with regard to the performance of trepanation: the regional trauma centers do not perform trepanation but nevertheless have the required material and personnel available. A similar result was recorded for local trauma centers. In the thoracic surgery section, it could be determined that almost all trauma centers that do not perform thoracotomy have the required material available. This group of trauma centers also stated that they have staff who can perform thoracotomy independently. The retrograde endovascular aortic occlusion procedure is possible in 88% of supraregional, 64% of regional and 10% of local trauma centers. Pelvic clamps and external fixators are available at all trauma centers. Conclusion The results of the survey show potential for optimization both in the area of framework conditions and in the care of patients. Consistent and specific training measures, for example, could improve the nationwide performance of these special interventions. Likewise, it must be discussed whether the abovementioned special procedures should be reserved for higher-level trauma centers.
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Affiliation(s)
- Nina Thies
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, Munich, Germany.
| | - Alexandra Zech
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, Munich, Germany
| | - Thorsten Kohlmann
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, University Hospital rechts der Isar, Technical University Munich, Munich, Germany
| | - Michael Bayeff-Filloff
- Bayerisches Staatsministerium des Innern für Sport und Integration, Ärztlicher Landesbeauftragter Rettungsdienst, Munich, Germany
| | - Karl-Georg Kanz
- Department of Trauma Surgery, University Hospital rechts der Isar, Technical University Munich, Munich, Germany
| | - Stephan Prückner
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, Munich, Germany
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Blood, balloons, and blades: State of the art trauma resuscitation. Am J Surg 2021; 224:40-44. [PMID: 34715985 DOI: 10.1016/j.amjsurg.2021.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 11/24/2022]
Abstract
Traumatic injury remains the leading cause of death in patients 45 and younger. State of the art trauma care requires rapid interventions to provide hemodynamic support en route to definitive hemostasis. This article will review three critical elements in management of the bleeding trauma patient: blood products, resuscitative endovascular balloon occlusion of the aorta (REBOA), and the trauma hybrid operating room (THOR).
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DuBose JJ, Burlew CC, Joseph B, Keville M, Harfouche M, Morrison J, Fox CJ, Mooney J, O'Toole R, Slobogean G, Marchand LS, Demetriades D, Werner NL, Benjamin E, Costantini T. Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control. J Trauma Acute Care Surg 2021; 91:e93-e103. [PMID: 34238857 DOI: 10.1097/ta.0000000000003331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined. LEVEL OF EVIDENCE Review, level IV.
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Affiliation(s)
- Joseph J DuBose
- From the R Adams Cowley Shock Trauma Center (J.J.D., M.K., M.H., J.M., C.J.F., R.O., G.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (C.C.B., N.L.W.), Denver Health Medical Center, Denver, Colorado; Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tucson, Arizona; Baylor University Medical Center (J.M.), Dallas, Texas; Department of Orthopedic Surgery (L.S.M.), University of Utah, Salt Lake City, Utah; Division of Trauma and Surgical Critical Care (D.D., E.B.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Trauma/Surgical Critical Care (T.C.), Grady Memorial Hospital/Emory University School of Medicine, Atlanta, Georgia; and Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.C.), University of California San Diego School of Medicine, San Diego, California
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Sadeghi M, Hurtsén AS, Tegenfalk J, Skoog P, Jansson K, Hörer TM, Nilsson KF. End-tidal Carbon Dioxide as an Indicator of Partial REBOA and Distal Organ Metabolism in Normovolemia and Hemorrhagic Shock in Anesthetized Pigs. Shock 2021; 56:647-654. [PMID: 34014885 DOI: 10.1097/shk.0000000000001807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION It is difficult to estimate the ischemic consequences when using partial resuscitative endovascular balloon occlusion of the aorta (REBOA). The aim was to investigate if end-tidal carbon dioxide (ETCO2) is correlated to degree of aortic occlusion, measured as distal aortic blood flow, and distal organ metabolism, estimated as systemic oxygen consumption (VO2), in a porcine model of normovolemia and hemorrhagic shock. MATERIALS AND METHODS Nine anesthetized pigs (25-32 kg) were subjected to incremental steps of zone 1 aortic occlusion (reducing distal aortic blood flow by 33%, 66%, and 100%) during normovolemia and hemorrhagic grade IV shock. Hemodynamic and respiratory variables, and blood samples, were measured. Systemic VO2 was correlated to ETCO2 and measures of partial occlusion previously described. RESULTS Aortic occlusion gradually lowered distal blood flow and pressure, whereas ETCO2, VO2 and carbon dioxide production decreased at 66% and 100% aortic occlusion. Aortic blood flow correlated significantly to ETCO2 during both normovolemia and hemorrhage (R = 0.84 and 0.83, respectively) and to femoral mean pressure (R = 0.92 and 0.83, respectively). Systemic VO2 correlated strongly to ETCO2 during both normovolemia and hemorrhage (R = 0.91 and 0.79, respectively), blood flow of the superior mesenteric artery (R = 0.77 and 0.85, respectively) and abdominal aorta (R = 0.78 and 0.78, respectively), but less to femoral blood pressure (R = 0.71 and 0.54, respectively). CONCLUSION ETCO2 was correlated to distal aortic blood flow and VO2 during incremental degrees of aortic occlusion thereby potentially reflecting the degree of aortic occlusion and the ischemic consequences of partial REBOA. Further studies of ETCO2, and potential confounders, in partial REBOA are needed before clinical use.
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Affiliation(s)
- Mitra Sadeghi
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anna Stene Hurtsén
- Centre for Clinical Research and Education, County Council of Värmland, Karlstad, Sweden
| | | | - Per Skoog
- Departments of Vascular Surgery and Institute of Medicine; Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden
| | - Kjell Jansson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Cralley AL, Moore EE, Scalea TM, Inaba K, Bulger EM, Meyer DE, Fox CJ, Sauaia A. Predicting success of resuscitative endovascular occlusion of the aorta: Timing supersedes variable techniques in predicting patient survival. J Trauma Acute Care Surg 2021; 91:473-479. [PMID: 34086662 DOI: 10.1097/ta.0000000000003307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular occlusion of the aorta (REBOA) is used for temporary aortic occlusion of trauma patients in the management of noncompressible hemorrhage. Previous studies have focused on how to properly perform REBOA in the trauma environment to improve survival rates, but high-grade evidence defining the ideal patient population does not yet exist. This post hoc analysis of the Emergent Truncal Hemorrhage Control Study seeks to identify the most important clinical factors for physicians to consider when selecting for REBOA candidates and their potential survival following REBOA. METHODS Post hoc analysis of a large, multicenter, prospective observational study conducted at six level 1 trauma centers, 2017 to 2018, was performed. An onsite data collector documented all time points for REBOA patients since admission. Candidate predictors were demographics; injury severity; physiology preprocedure, during procedure, and postprocedure; cardiopulmonary resuscitation; and REBOA-specific variables (time to procedure, procedure-related time intervals, access site, technique, sheath size, catheter length, balloon volume, deployment zone). Predictive models for survival at three different time points along the trauma triage and REBOA process timeline ("Admission," "REBOA Initiation," and "Postaortic Occlusion") were devised by logistic regression. RESULTS Eighty-eight patients had REBOA placement. The Admission model selected age, Glasgow Coma Scale, and admission systolic blood pressure as significant predictors of survival (area under the receiver operating characteristic curve [AUROC], 0.86; 95% CI, 0.77-0.94). The REBOA Initiation and Postaortic Occlusion models selected age, Glasgow Coma Scale, and the systolic blood pressure measured just before balloon inflation as predictors for survival (AUROC, 0.87 [95% CI, 0.78-0.97] and AUROC, 0.90 [95% CI, 0.81-0.99], respectively). No REBOA procedural variables were identified as predictors of patient survival. CONCLUSION Only patient-specific criteria of age, neurologic status, and severity of shock predicted survival. The hemodynamic stability of the patient at the time REBOA is initiated is more important than how REBOA is initiated. These findings suggest that earlier preparation for REBOA placement may be a key to improved survival. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Alexis L Cralley
- From the Department of Surgery (A.L.C., E.E.M.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (T.M.S., C.J.F.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Department of Surgery (E.M.B.), University of Washington School of Medicine, Seattle, Washington; Department of Surgery at UT Health (D.E.M.), Texas Health Science Center's McGovern Medical School, Houston, Texas; Colorado School of Public Health (A.S.), Aurora, Colorado
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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Zone I Balloon Occlusion Time Affects Spinal Cord Injury in the Nonhuman Primate Model. Ann Surg 2021; 274:e54-e61. [PMID: 31188208 DOI: 10.1097/sla.0000000000003408] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used clinically to limit torso bleeding and restore central perfusion. The objective of this study was to determine the sequelae of prolonged REBOA in a nonhuman primate animal model. SUMMARY BACKGROUND DATA Prolonged duration of REBOA is associated with adverse clinical outcomes. Threshold occlusion values tied to relative risk have yet to be determined. METHODS Juvenile baboons were subjected to 40% to 55% total blood volume hemorrhage to achieve profound hypotension and shock. Zone I REBOA was performed for 60 minutes to assess acute injury and survival at 4 hours (group 1; n = 7). Post-REBOA 10-day survival and complications were then compared between 60 minutes (group 2; n = 8) and 30 minutes (group 3; n = 6) REBOA animals. RESULTS Overall survival was 20/21 (95%). IL-6 and IL-8 were elevated at 1 and 4 hours in group 1 (P = 0.005; P = 0.001). Comparing 60-minute REBOA with 30-minute REBOA, there was (1) hypertension compared with normotension (P = 0.005), (2) increased base deficit (P = 0.003), (3) elevated Troponin I (P = 0.04), and histological evidence of kidney injury (P = 0.004). In addition, group 2 demonstrated paralysis with histopathologic changes of spinal cord ischemia (SCI) in 4/8 (50%), with no SCI in group 3 (P = 0.033). CONCLUSIONS REBOA limits mortality in the primate model of severe hemorrhagic shock. However, unopposed balloon inflation in the distal thoracic aorta for 60 minutes results in high rates of spinal cord ischemia, an effect mitigated by limiting balloon inflation to 30 minutes.
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Otsuka H, Takeda M, Sai K, Sakoda N, Uehata A, Sato T, Sakurai K, Aoki H, Yamagiwa T, Iizuka S, Inokuchi S. Is resuscitative endovascular balloon occlusion of the aorta for computed tomography diagnosis feasible or not? A Japanese single-center, retrospective, observational study. J Trauma Acute Care Surg 2021; 91:287-294. [PMID: 34397952 DOI: 10.1097/ta.0000000000003193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management. METHODS This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020. RESULTS All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis. CONCLUSION In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed. LEVEL OF EVIDENCE Therapeutic/care management study, level V.
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Affiliation(s)
- Hiroyuki Otsuka
- From the Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
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Stokes SC, Theodorou CM, Zakaluzny SA, DuBose JJ, Russo RM. Resuscitative endovascular balloon occlusion of the aorta in combat casualties: The past, present, and future. J Trauma Acute Care Surg 2021; 91:S56-S64. [PMID: 33797487 PMCID: PMC8324517 DOI: 10.1097/ta.0000000000003166] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Noncompressible torso hemorrhage is a leading cause of preventable death on the battlefield. Intra-aortic balloon occlusion was first used in combat in the 1950s, but military use was rare before Operation Iraqi Freedom and Operation Enduring Freedom. During these wars, the combination of an increasing number of deployed vascular surgeons and a significant rise in deaths from hemorrhage resulted in novel adaptations of resuscitative endovascular balloon occlusion of the aorta (REBOA) technology, increasing its potential application in combat. We describe the background of REBOA development in response to a need for minimally invasive intervention for hemorrhage control and provide a detailed review of all published cases (n = 47) of REBOA use for combat casualties. The current limitations of REBOA are described, including distal ischemia and reperfusion injury, as well as ongoing research efforts to adapt REBOA for prolonged use in the austere setting. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Sarah C. Stokes
- Department of Surgery, University of California-Davis, Sacramento, California
| | | | - Scott A. Zakaluzny
- Department of Surgery, University of California-Davis, Sacramento, California
- Department of General Surgery, David Grant USAF Medical Center, Travis, California
| | - Joseph J. DuBose
- Department of Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Department of Vascular Surgery, United States Air Force, Baltimore, Maryland
| | - Rachel M. Russo
- Department of Surgery, University of California-Davis, Sacramento, California
- Department of General Surgery, David Grant USAF Medical Center, Travis, California
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Hadley JB, Coleman JR, Moore EE, Lawless R, Burlew CC, Platnick B, Pieracci FM, Hoehn MR, Coleman JJ, Campion EM, Cohen MJ, Cralley A, Eitel AP, Bartley M, Vigneshwar N, Sauaia A, Fox CJ. Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center. J Trauma Acute Care Surg 2021; 91:295-301. [PMID: 33783417 PMCID: PMC8375411 DOI: 10.1097/ta.0000000000003198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. LEVEL OF EVIDENCE Therapeutic, level V.
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Affiliation(s)
- Jamie B Hadley
- From Department of Surgery, University of Colorado School of Medicine (J.B.H., J.R.C., A.P.E., M.B., N.V., C.J.F.); and Department of Surgery, Denver Health Medical Center (E.E.M., R.L., C.C.B., B.P., F.M.P., M.R.H., J.J.C., E.M.C., M.J.C., A.S., A.C.), Denver, Colorado
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Shi C, Li S, Wang Z, Shen H. Prehospital aortic blood flow control techniques for non-compressible traumatic hemorrhage. Injury 2021; 52:1657-1663. [PMID: 33750584 DOI: 10.1016/j.injury.2021.02.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy.
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Affiliation(s)
- Changgui Shi
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Song Li
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhinong Wang
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Hongliang Shen
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China.
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Gamberini L, Coniglio C, Lupi C, Tartaglione M, Mazzoli CA, Baldazzi M, Cecchi A, Ferri E, Chiarini V, Semeraro F, Gordini G. Resuscitative endovascular occlusion of the aorta (REBOA) for refractory out of hospital cardiac arrest. An Utstein-based case series. Resuscitation 2021; 165:161-169. [PMID: 34089774 DOI: 10.1016/j.resuscitation.2021.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 12/18/2022]
Abstract
AIMS Out of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA. Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons. We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA. METHODS Twenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded. RESULTS Successful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure. Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min. An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died. CONCLUSION Our data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC. However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.
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Affiliation(s)
- Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Marzia Baldazzi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Alessandra Cecchi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Enrico Ferri
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Federico Semeraro
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy.
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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Godø BN, Brede JR, Krüger AJ. Needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major haemorrhage: a cross-sectional study. Emerg Med J 2021; 39:521-526. [PMID: 34039645 PMCID: PMC9234412 DOI: 10.1136/emermed-2020-210808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/15/2021] [Accepted: 04/25/2021] [Indexed: 11/16/2022]
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) can be used as an adjunct treatment in traumatic abdominopelvic haemorrhage, ruptured abdominal aortic aneurysms, postpartum haemorrhage (PPH), gastrointestinal bleeding and iatrogenic injuries during surgery. This needs assessment study aims to determine the number of patients eligible for REBOA in a typical Norwegian population. Methods This was a retrospective cross-sectional study based on data obtained from blood bank registries and the Norwegian Trauma Registry for the years 2017–2018. Patients who received ≥4 units of packed red blood cells (PRBCs) within 6 hours and met the anatomical criteria for REBOA or patients with relevant Abbreviated Injury Scale codes with concurrent hypotension or transfusion of ≥4 units of PRBCs within 6 hours were identified. A detailed two-step chart review was performed to identify potentially eligible REBOA candidates. Descriptive data were collected and compared between subgroups using non-parametric tests for statistical significance. Results Of 804 patients eligible for inclusion, 53 patients were regarded as potentially REBOA eligible (corresponding to 5.7 per 100 000 adult population/year). Of these, 19 actually received REBOA. Among the identified eligible patients, 44 (83%) had a non-traumatic aetiology. Forty-two patients (79%) were treated at a tertiary care hospital. Fourteen (78%) of the REBOA procedures were due to PPH. Conclusion The number of patients potentially eligible for REBOA after haemorrhage is low, and most cases are non-traumatic. Most patients were treated at a tertiary care hospital. The exclusion of non-traumatic patients results in a substantial underestimation of the number of potentially REBOA-eligible patients.
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Affiliation(s)
- Bård Neuenkirchen Godø
- Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jostein Rodseth Brede
- Department of Anesthesiology and Intensive Care Medicine, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway.,Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology Faculty of Medicine and Health Sciences, Trondheim, Sør-Trøndelag, Norway
| | - Andreas Jorstad Krüger
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology Faculty of Medicine and Health Sciences, Trondheim, Sør-Trøndelag, Norway
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49
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Pulmonary Vasodilation by Intravenous Infusion of Organic Mononitrites Of 1,2-Propanediol in Acute Pulmonary Hypertension Induced by Aortic Cross Clamping and Reperfusion: A Comparison With Nitroglycerin in Anesthetized Pigs. Shock 2021; 54:119-127. [PMID: 31425404 DOI: 10.1097/shk.0000000000001436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Suprarenal aortic cross clamping (SRACC) and reperfusion may cause acute pulmonary hypertension and multiple organ failure. HYPOTHESIS The organic mononitrites of 1,2-propanediol (PDNO), an nitric oxide donor with a very short half-life, are a more efficient pulmonary vasodilator and attenuator of end-organ damage and inflammation without significant side effects compared with nitroglycerin and inorganic nitrite in a porcine SRACC model. METHODS Anesthetized and instrumented domestic pigs were randomized to either of four IV infusions until the end of the experiment (n = 10 per group): saline (control), PDNO (45 nmol kg min), nitroglycerin (44 nmol kg min), or inorganic nitrite (a dose corresponding to PDNO). Thereafter, all animals were subjected to 90 min of SRACC and 10 h of reperfusion and protocolized resuscitation. Hemodynamic and respiratory variables as well as blood samples were collected and analysed. RESULTS During reperfusion, mean pulmonary arterial pressure and pulmonary vascular resistance were significantly lower, and stroke volume was significantly higher in the PDNO group compared with the control, nitroglycerin, and inorganic nitrite groups. In parallel, mean arterial pressure, arterial oxygenation, and fraction of methaemoglobin were similar in all groups. The serum concentration of creatinine and tumor necrosis factor alpha were lower in the PDNO group compared with the control group during reperfusion. CONCLUSIONS PDNO was an effective pulmonary vasodilator and appeared superior to nitroglycerin and inorganic nitrite, without causing significant systemic hypotension, impaired arterial oxygenation, or methaemoglobin formation in an animal model of SRACC and reperfusion. Also, PDNO may have kidney-protective effects and anti-inflammatory properties.
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50
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Kuang B, Dawson J. The resuscitation of REBOA. ANZ J Surg 2021; 90:428-429. [PMID: 32339424 DOI: 10.1111/ans.15548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/25/2019] [Accepted: 10/01/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Beatrice Kuang
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joseph Dawson
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Surgical Trauma and Oncology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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